Autumn Lake Healthcare at Bucks Hill

Inspectors wroteBased on observations, staff interviews, facility documentation, and facility policy during a tour of the Food Services Department, the facility failed to ensure dishwasher temperatures were maintained according to the manufacturer's requirement to adequately sanitize dishware.

Inspectors wroteBased on observations, facility documentation, interviews, and facility policy , the facility failed to ensure resident food was served at a safe temperature and was appetizing.

Inspectors wroteBased on interviews and record reviews for the only sampled resident, (Resident #329), reviewed for advance directives, the facility failed to ensure the advance directives consent was signed and available.

Inspectors wroteBased on interviews, review of clinical record, and facility policy for the only sampled resident, (Resident #27), reviewed for personal property, the facility failed to report the loss of a resident's personal belonging to the State Agency within the 24-hour time requirement.

Inspectors wroteBased on staff interviews and review of the clinical record for the only sampled resident, (Resident #44), reviewed for Activities of Daily Living (ADL's), the facility failed to prevent a decline in transfer and ambulation (walking) abilities.

Inspectors wroteBased on observations, review of the clinical record, facility policy and the interview for the only sampled resident (Resident #22) reviewed for activities of daily living, the facility failed to maintain clean and trimmed fingernails.

Inspectors wroteBased on clinical record review, observations, and interviews for the only sampled resident (Resident #5) reviewed for respiratory care, the facility failed to follow a hospital discharge order for specialist consultation.

Inspectors wroteBased on review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #39) reviewed for pressure ulcers, the facility failed to ensure weekly skin checks (body audits) were conducted per the physician orders, and failed to ensure that a Registered Nurse (RN) assessment was conducted for a resident who was readmitted to the facility with a pressure ulcer.

Inspectors wroteBased on observations, review of the clinical record, facility policies and interviews for the only sampled resident (Resident #22) reviewed for positioning and mobility, the facility failed to apply a left wrist hand splint as ordered.

Inspectors wroteBased on staff interviews, review of the clinical record, and review of facility policy for 2 of 5 sampled residents, (Resident #44 and Resident #281), reviewed for nutrition/hydration status, for Resident #44 the facility failed to weigh the resident monthly, failed to reweigh the resident after a 5 pound weight loss, and failed to ensure the dietician re-evaluated the resident after a weight loss and per the physician's order, and for Resident #281 failed to complete and appropriately document weights for a resident who was newly admitted , underweight and malnourished.

Inspectors wroteBased on observations, interviews, review of the clinical record, and facility policy for 2 of 5 residents (Resident #41 and Resident #59) reviewed for infection control, the facility failed to ensure appropriate Personal Protective Equipment (PPE) use during high contact care for residents who required Enhanced Barrier Precautions (EBP).

Inspectors wroteBased on observations and interviews for 1 of 2 tub rooms, the facility failed to provide a homelike, sanitary, and safe environment.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for quality of care, the facility failed to ensure a follow-up specialist appointment was scheduled timely after a new admission, and failed to ensure timely notification to the dialysis center of physician orders for medication administration at the dialysis center.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one of three sampled residents (Resident #1) who had poor decision-making skills regarding tasks of daily life, the facility failed to notify the Power of Attorney at the time the resident experienced a change in condition, and a new medication and laboratory blood work were recommended by a medical provider.

Inspectors wroteBased on clinical record reviews, facility documentation, policy, and interviews for one of three sampled residents (Resident #1) who had potential for impairment to skin integrity, the facility failed to conduct and document an initial wound assessment when blisters were identified.

Inspectors wroteBased on clinical record reviews, facility documentation, policy, and interviews for one of three sampled residents (Resident #1) who had potential for impairment to skin integrity, the facility failed to conduct and document weekly skin assessments in accordance with the physician's order.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one of three sampled residents (Resident #1) who was reviewed for a change in condition, the facility failed to follow the physician's order and obtain the laboratory blood work that was ordered.

Inspectors wroteBased on review of facility documentation, review of facility policy, and interviews the facility failed to respond to resident council concerns.

Inspectors wroteObservations on 8/15/22 of resident room [ROOM NUMBER] and the [NAME] unit shower room identified the following: • Dust build up on the surfaces surrounding the TV • Overflowing garbage container that appear to not have been emptied • The bathroom was noted to have debris on the floor • A small amount of brown buildup was noted on the bathroom door jamb • There appeared to be heavy dust buildup that hung from the bathroom ceiling • There were a large number of dead insects observed in the clear glass overhead light in the bathroom. • The shower seat located in the shower room had brownish colored buildup along the sides of the shower seat. An interview on 8/15/22 at 10:50 AM with Resident #6 (alert and oriented) identified that the housekeeping staff did not clean the bedroom, bathroom, and shower room on a regular basis. [...]

Inspectors wroteBased on review of the clinical record, review of facility documentation, review of facility policy, and interviews for two of four sampled residents (Residents #25 and #67) reviewed for Preadmission Screening and Resident Review (PASRR) the facility failed to ensure the MDS was coded to indicate the residents had a serious mental illness.

Inspectors wroteBased on review of the clinical record, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #78) reviewed for discharge, the facility failed to ensure the clinical record was complete.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 4 of 8 sampled residents reviewed for Pneumococcal immunization (Resident #4, Resident #18, Resident #34 and Resident #37), the facility failed to offer/administer the Pneumococcal vaccine according to Centers for Disease Control guidelines.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one of one sampled resident reviewed for an allegation of abuse (Resident #225), the facility failed to conduct a thorough investigation prior to determining the allegation to be unsubstantiated.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for one of nine sampled residents reviewed for dining (Resident #55), the facility failed to follow the Resident Care Plan (RCP) regarding the removal of a left half lap tray during meals.